The most appropriate response by the nurse is:
"Ice packs can be used to reduce swelling but should be removed after 20 minutes."
The nurse is caring for four clients. Which of these clients will the nurse see first?
A client with a urinary tract infection who has a fever of 38.5°C and flank pain
A client with a deep vein thrombosis who has a positive Homans' sign and edema in the affected leg
A client with a myocardial infarction who has chest pain and shortness of breath
A client with a stroke who has slurred speech and facial droop
The Correct Answer is C
Choice A reason: This is not the highest priority client because a urinary tract infection (UTI) is a common and treatable condition that affects the lower urinary system, such as the bladder or urethra. A fever of 38.5°C and flank pain can indicate that the infection has spread to the upper urinary system, such as the kidneys, which can cause pyelonephritis. Pyelonephritis is a serious but not lifethreatening complication that requires antibiotic therapy and hydration. The nurse should monitor the client's vital signs, urine output, and pain level and administer the prescribed medication and fluids.
Choice B reason: This is not the highest priority client because a deep vein thrombosis (DVT) is a blood clot that forms in a deep vein, usually in the lower extremities. A positive Homans' sign and edema in the affected leg can indicate that the clot is causing inflammation and obstruction of the blood flow. DVT is a serious but not lifethreatening complication that requires anticoagulant therapy and compression therapy. The nurse should monitor the client's vital signs, leg circumference, and pain level and administer the prescribed medication and stockings.
Choice C reason: This is the highest priority client because a myocardial infarction (MI) is a heart attack that occurs when the blood flow to a part of the heart muscle is blocked, causing tissue damage or death. Chest pain and shortness of breath can indicate that the client is experiencing acute cardiac ischemia, which can lead to cardiac arrest or heart failure. MI is a lifethreatening emergency that requires immediate intervention and treatment. The nurse should activate the rapid response team, monitor the client's vital signs, electrocardiogram, and oxygen saturation, and administer the prescribed medication and oxygen.
Choice D reason: This is not the highest priority client because a stroke is a brain attack that occurs when the blood flow to a part of the brain is interrupted, causing tissue damage or death. Slurred speech and facial droop can indicate that the client is experiencing acute neurological impairment, which can affect their communication and facial expression. Stroke is a serious but not lifethreatening complication that requires prompt evaluation and treatment. The nurse should monitor the client's vital signs, neurological status, and glucose level and administer the prescribed medication and fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is an unrealistic and unattainable goal for a client with rheumatoid arthritis. Rheumatoid arthritis is a chronic and progressive inflammatory disease that causes joint pain, stiffness, swelling, and deformity. It is not possible to eliminate pain completely with this condition. The nurse should help the client set realistic and individualized goals for pain management.
Choice B reason: This is a vague and subjective goal for pain control. Pain is a personal and multidimensional experience that varies from person to person. The nurse should use a valid and reliable pain assessment tool, such as the numeric rating scale, to measure the client's pain intensity and quality. The nurse should also ask the client about their acceptable level of pain and how it affects their daily activities and quality of life.
Choice C reason: This is a good goal for general health and wellness, but it is not specific to pain control. Eating healthy meals and staying hydrated can help the client maintain their nutritional status and hydration, which are important for overall health. However, they do not directly address the pain caused by rheumatoid arthritis. The nurse should also consider other factors that can influence pain, such as stress, mood, sleep, and coping strategies.
Choice D reason: This is the best goal for pain control in a client with rheumatoid arthritis. It is realistic, measurable, and individualized. It acknowledges that some pain is inevitable with this condition, but it aims to reduce it to a tolerable level that allows the client to function and enjoy life. It also uses a numeric rating scale to quantify the pain and monitor the effectiveness of interventions.
Correct Answer is C
Explanation
Choice A reason: Culturing the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a sterile technique.
Choice B reason: Applying topical ointment to the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Applying topical ointment to the wound is a procedure that involves applying a medication or a dressing to the wound site, which can help prevent or treat infection, inflammation, or pain. Applying topical ointment to the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a clean technique.
Choice C reason: Inspecting the wound and assessing the drainage is the nurse's priority assessment for this client, because it is the most urgent and relevant action. Inspecting the wound and assessing the drainage is a process that involves observing and measuring the wound site and the wound exudate, which can reveal the presence and severity of infection, injury, or healing. Inspecting the wound and assessing the drainage is an essential assessment, as it can guide the diagnosis, treatment, and evaluation of the client's condition.
Choice D reason: Calling the provider to initiate antibiotics is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Calling the provider to initiate antibiotics is a communication that involves reporting the client's situation and requesting a prescription for an antimicrobial agent, which can help fight or prevent infection. Calling the provider to initiate antibiotics is an important communication, but it should be done after inspecting the wound and assessing the drainage, and with the necessary data and documentation.
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